Factors influencing diabetes treatment satisfaction in the INtegrating DEPrEssioN and Diabetes treatmENT randomized clinical trial: A multilevel model analysis.

AIMS: Patient satisfaction is associated with positive diabetes outcomes. However, there are no identified studies that evaluate both patient- and clinic-level predictors influencing diabetes care satisfaction longitudinally. METHODS: Data from the INtegrating DEPrEssioN and Diabetes treatmENT trial was used to perform the analysis. We used fixed and random effects models to assess whether and how changes in patient-level predictors (treatment assignment, depression symptom severity, systolic blood pressure, body mass index, LDL cholesterol, and haemoglobin A1C) from 0 to 24 months and clinic-level predictors (visit frequency, visit cost, number of specialists, wait time, time spent with healthcare provider, and receiving verbal reminders) measured at 24 months influence diabetes care satisfaction from 0 to 24 months. RESULTS: Model 1 (patient-level predictors) accounted for 7% of the change in diabetes satisfaction and there was a significant negative relationship between change in depressive symptoms and care satisfaction (ß = -0.23, SE = 0.12, p < 0.05). Within Model 1, 2% of the variance was explained by clinic-level predictors. Model 2 included both patient- and clinic-level predictors and accounted for 18% of the change in diabetes care satisfaction. Within Model 2, 9% of the variance was attributed to clinic-level predictors. There was also a cross-level interaction where the change in depression had less of an impact on the change in satisfaction for those who received a verbal reminder (ß = -0.11, SE = 0.21, p = 0.34) compared with those who did not receive a reminder (ß = -0.62, SE = 0.08, p < 0.01). CONCLUSIONS: Increased burden of depressive symptoms influences diabetes care satisfaction. Clinic-level predictors also significantly influence diabetes care satisfaction and can reduce dissatisfaction in primary care, specifically, reminder calls from clinic staff.

Collaborative implementation of an evidence-based package of integrated primary mental healthcare using quality improvement within a learning health systems approach: Lessons from the Mental health INTegration programme in South Africa.

Introduction: The treatment gap for mental health disorders persists in low- and middle-income countries despite overwhelming evidence of the efficacy of task-sharing mental health interventions. Key barriers in the uptake of these innovations include the absence of policy to support implementation and diverting of staff from usual routines in health systems that are already overstretched. South Africa enjoys a conducive policy environment; however, strategies for operationalizing the policy ideals are lacking. This paper describes the Mental health INTegration Programme (MhINT), which adopted a health system strengthening approach to embed an evidence-based task-sharing care package for depression to integrate mental health care into chronic care at primary health care (PHC). Methods: The MhINT care package consisting of psycho-education talks, nurse-led mental health assessment, and a structured psychosocial counselling intervention provided by lay counsellors was implemented in Amajuba district in KwaZulu-Natal over a 2-year period. A learning health systems approach was adopted, using continuous quality improvement (CQI) strategies to facilitate embedding of the intervention.MhINT was implemented along five phases: the project phase wherein teams to drive implementation were formed; the diagnostic phase where routinely collected data were used to identify system barriers to integrated mental health care; the intervention phase consisting of capacity building and using Plan-Do-Study-Act cycles to address implementation barriers and the impact and sustaining improvement phases entailed assessing the impact of the program and initiation of system-level interventions to sustain and institutionalize successful change ideas. Results: Integrated planning and monitoring were enabled by including key mental health service indicators in weekly meetings designed to track the performance of noncommunicable diseases and human immunovirus clinical programmes. Lack of standardization in mental health screening prompted the validation of a mental health screening tool and testing feasibility of its use in centralized screening stations. A culture of collaborative problem-solving was promoted through CQI data-driven learning sessions. The province-level screening rate increased by 10%, whilst the district screening rate increased by 7% and new patients initiated to mental health treatment increased by 16%. Conclusions: The CQI approach holds promise in facilitating the attainment of integrated mental health care in resource-scarce contexts. A collaborative relationship between researchers and health system stakeholders is an important strategy for facilitating the uptake of evidence-based innovations. However, the lack of interventions to address healthcare workers' own mental health poses a threat to integrated mental health care at PHC.

Amigas Latinas Motivando el Alma: Participant Perspectives on an In-Person and Online Implementation of an Intervention to Promote Mental Health in Latina Immigrant Women.

Amigas Latinas Motivando el Alma is a community-based intervention designed to increase social support and coping strategies among Latina immigrant women at risk for depression and anxiety. To assess satisfaction and perceived efficacy of the intervention, we conducted interviews with 32 participants that received the intervention in-person and online. Participants across both modalities found the program supportive in maintaining their mental health. They learned stress management techniques and found the support from facilitators and other participants helpful. Those receiving the intervention in-person were able to connect with other participants more easily than those that received it online. Those receiving it online noted distractions at home that made it challenging to fully engage. Community-based interventions that promote coping strategies and social support are a promising strategy for addressing mental health disparities among Latina immigrant women.TRN: NCT03749278, date of registration: November 21, 2018.

Flexible B12 ecophysiology of Phaeocystis antarctica due to a fusion B12-independent methionine synthase with widespread homologues.

Coastal Antarctic marine ecosystems are significant in carbon cycling because of their intense seasonal phytoplankton blooms. Southern Ocean algae are primarily limited by light and iron (Fe) and can be co-limited by cobalamin (vitamin B12). Micronutrient limitation controls productivity and shapes the composition of blooms which are typically dominated by either diatoms or the haptophyte Phaeocystis antarctica. However, the vitamin requirements and ecophysiology of the keystone species P. antarctica remain poorly characterized. Using cultures, physiological analysis, and comparative omics, we examined the response of P. antarctica to a matrix of Fe-B12 conditions. We show that P. antarctica is not auxotrophic for B12, as previously suggested, and identify mechanisms underlying its B12 response in cultures of predominantly solitary and colonial cells. A combination of proteomics and proteogenomics reveals a B12-independent methionine synthase fusion protein (MetE-fusion) that is expressed under vitamin limitation and interreplaced with the B12-dependent isoform under replete conditions. Database searches return homologues of the MetE-fusion protein in multiple Phaeocystis species and in a wide range of marine microbes, including other photosynthetic eukaryotes with polymorphic life cycles as well as bacterioplankton. Furthermore, we find MetE-fusion homologues expressed in metaproteomic and metatranscriptomic field samples in polar and more geographically widespread regions. As climate change impacts micronutrient availability in the coastal Southern Ocean, our finding that P. antarctica has a flexible B12 metabolism has implications for its relative fitness compared to B12-auxotrophic diatoms and for the detection of B12-stress in a more diverse set of marine microbes.

The Impact of a Collaborative Care Model on Health Trajectories among Patients with Co-Morbid Depression and Diabetes: The INDEPENDENT Study.

Context: Collaborative care models for depression have been successful in a variety of settings, but their success may differ by patient engagement. We conducted a post-hoc analysis of the INDEPENDENT trial to investigate the role of differential engagement of participants on health outcomes over 3 years. Settings and Design: INDEPENDENT study was a parallel, single-blinded, randomised clinical trial conducted at four socio-economically diverse clinics in India. Participants were randomised to receive either active collaborative care or usual care for 12 months and followed up for 24 months. Method: We grouped intervention participants by engagement, defined as moderate (≤7 visits) or high, (8 or more visits) and compared them with usual care participants. Improvements in composite measure (depressive symptoms and at least one of three cardio-metabolic) were the primary outcome. Statistical Analysis: Mean levels of depression and cardio-metabolic measures were analysed over time using computer package IBM SPSS Statistics 25. Results: The composite outcome was sustained the highest in the moderate engagers [27.5%, 95% confidence interval (CI): 19.5, 36.7] and the lowest in high engagers (15.8%, 95% CI: 8.1, 26.8). This pattern was observed for individual parameters - depressive symptoms and glycosylated haemoglobin. Progressive reductions in mean depressive symptom scores were observed for moderate engagers and usual care group from baseline to 36 months. However, in high engagers of collaborative care, mean depressive symptoms were higher at 36 months compared to 12 months. Conclusion: Sustained benefits of collaborative care were larger in participants with moderate engagement compared with high engagement, although a majority of participants relapsed on one or more outcome measures by 36 months. High engagers of collaborative care for co-morbid depression and diabetes may need light touch interventions for longer periods to maintain health and reduce depressive symptoms.

Geographic distribution and determinants of mental health stigma in central Mozambique

Purpose: This study describes patterns of community-level stigmatizing attitudes towards mental illness (MI) in central Mozambique. Methods: Data for this study come from a representative community household survey of 2933 respondents ≥ 18 years old in Manica and Sofala Provinces, Mozambique. Six MI stigma questions represented primary research outcomes. Bivariate and multivariable analyses examined the relationship between key explanatory factors and each stigma question. Spatial analyses analyzed the smoothed geographic distribution of responses to each question and explored the association between geographic location and MI stigma controlling for individual-level socio-demographic factors. Results: Stigmatizing attitudes towards MI are prevalent in central Mozambique. Analyses showed that males, people who live in urban places, divorced and widowed individuals, people aged 18-24, people with lower education, people endorsing no religion, and people in lower wealth quintiles tended to have significantly higher levels of stigmatizing attitudes towards MI. Individuals reporting depressive symptoms scored significantly higher on stigmatizing questions, potentially indicating internalized stigma. Geographic location is significantly associated with people's response to five of the stigma questions even after adjusting for individual-level factors. Conclusion: Stigmatizing attitudes towards MI are common in central Mozambique and concentrated amongst specific socio-demographic groups. However, geographic analyses suggest that structural factors within communities and across regions may bear a greater influence on MI stigma than individual-level factors alone. Further implementation science should consider focusing on identifying the most significant modifiable structural factors associated with MI stigma in LMICs to inform the development, testing, and optimization of multi-level stigma prevention interventions.